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.

Clinical outcomes of splenic arterial embolization for blunt splenic injury in pediatric and adolescent patients.

BACKGROUND: Splenic arterial embolization (SAE) is an effective intervention for the management of arterial hemorrhage asso-ciated with blunt splenic injury. However, its role and clinical outcomes in pediatric and adolescent patients are unclear. The aim of this study is to assess the role and the clinical outcomes of SAE for blunt splenic injuries in pediatric and adolescent trauma patients. METHODS: A retrospective cohort study was performed in patients aged ≤17 years with blunt splenic injury transferred to a re-gional trauma center in a tertiary referral hospital between November 01, 2015, and September 30, 2020. The final study population consisted of 40 pediatric and adolescent patients with blunt splenic injuries. The patient demographics, mechanisms of injury, details of injuries, angiographic findings, embolization techniques, and technical and clinical outcomes, including spleen salvage rates and pro-cedure-related complications, were examined. RESULTS: Of the 40 pediatric and adolescent patients with blunt splenic injury, 17 underwent SAE (42.53%). The clinical success rate was 88.2% (15/17). No cases of embolization-related complications or clinical failure were observed. Spleen salvage after SAE was achieved in all patients. In addition, no statistically significant differences were observed in clinical outcomes (clinical success and spleen salvage rates) between low-grade (World Society of Emergency Surgery [WSES] spleen trauma classification I or II) and high-grade (WSES classification III or IV) splenic injury groups. CONCLUSION: SAE is a safe and feasible procedure, and is effective for successful spleen salvage of blunt splenic injuries in pediatric and adolescent patients.

Time to Splenic Angioembolization Does Not Impact Splenic Salvage Rates.

We aimed to determine whether early (<6 hours) vs delayed (≥6 hours) splenic angioembolization (SAE) after blunt splenic trauma (grades II-V) impacted splenic salvage rates at a level I trauma center (2016-2021). The primary outcome was delayed splenectomy by timing of SAE. Mean time of SAE was determined for those who failed vs those who had successful splenic salvage. We retrospectively identified 226 individuals, from which 76 (33.6%) were in the early group and 150 (66.4%) were in the delayed group. The early group had higher AAST grade, greater amount of hemoperitoneum on CT, and 3.9x greater odds of undergoing delayed splenectomy (P = .046). Time to embolization was shorter in the group that failed splenic salvage (5 vs 10 hours, P = .051). On multivariate analysis, timing of SAE had no effect on splenic salvage. This study supports performing SAE on an urgent rather than emergent basis in stable patients after blunt splenic injury.

Distal Pancreatic Necrosis After Splenic Angioembolization.

Pancreatic ischemia with necrosis is an extremely rare complication of splenic angioembolization (SAE). A 48-year-old male with a grade IV blunt splenic injury underwent angiography which demonstrated no active bleeding or pseudoaneurysm. Proximal SAE was performed. One week later, he developed severe sepsis. Repeat CT imaging showed nonperfusion of the distal pancreas, and laparotomy found necrosis of approximately 40% of the pancreas. Distal pancreatectomy and splenectomy were performed. He endured a prolonged hospital course with multiple complications. Clinicians should have a high index of suspicion for ischemic complications after SAE when sepsis develops.

Management of High Grade Splenic Injuries in Rural America.

BACKGROUND: Rural surgeons face unique challenges when managing patients with high-grade (III-V) blunt splenic injury (BSI) given limited access to interventional radiology and blood products. Patients therefore may require transfer for splenic artery embolization (SAE) when resuscitation may still be ongoing. This study aims to evaluate current resource utilization in a rural trauma population with limited access to SAE and blood products. METHODS: Retrospective analysis of adult patients with high-grade BSI at one Level 1 trauma center and two Level 2 trauma centers was performed. Patients were evaluated for resources used after transfer to the regional trauma center. Primary outcomes measured were SAE, operative management (OM), and blood product utilization. Secondary outcomes measured included injury severity score (ISS) and mortality. RESULTS: Final analysis included 134 transferred patients. 16% underwent SAE, 16% underwent OM, and 69% were treated successfully with nonoperative and non-procedural management (NOM). 52% of the SAE patients had sustained a grade III splenic injury, 38% grade IV, and 10% grade V. 84% of patients required <3 units of packed red blood cells (PRBC) and 57% of patients required none. 80% of transferred patients required <3 total units of all combined blood products. DISCUSSION: The majority of patients with BSI transferred to a tertiary trauma center from a rural facility were successfully managed without SAE and required minimal transfusion of blood products. In the absence of other injuries necessitating transfer to a tertiary trauma center, rural surgeons should consider management of high grade splenic injuries at their home institution.

Delayed splenic pseudoaneurysm identification with surveillance imaging.

BACKGROUND: Recent studies have shown that nonoperative management of patients with splenic injury has up to a 90% success rate. However, delayed hemorrhage secondary to splenic artery pseudoaneurysm occurs in 5% to 10% of patients with up to 27% of patients developing a pseudoaneurysm on delayed imaging. The goal of our study was to evaluate the safety and utility of delayed computed tomography (CT) imaging for blunt splenic injury patients. METHODS: A retrospective evaluation of all traumatic splenic injuries from 2018 to 2020 at a single level 1 trauma center was undertaken. Patients were subdivided into four groups based on the extent of splenic injury: grades I and II, grade III, grade IV, and grade V. Patient injury characteristics along with hospital length of stay, imaging, procedures, and presence/absence of pseudoaneurysm were documented. RESULTS: A total of 588 trauma patients were initially included for evaluation, with 539 included for final analysis. Two hundred ninety-seven patients sustained grades I and II; 123 patients, grade III; 61 patients, grade IV; and 58 patients, grade V splenic injuries. One hundred twenty-nine patients (24%) underwent either emergent or delayed (>6 hours) splenectomy with an additional six patients having a splenorrhaphy on initial operation. Of the patients who were treated nonoperatively, 98% of grade III, 91% of grade IV, and 100% of grade V splenic injury patients underwent follow-up CT imaging. The mean ± SD time from admission to follow-up abdominal CT scan was 5 ± 4.4 days. Twenty-two pseudoaneurysms were identified including grade III (10 of 84), grade IV (7 of 22), and grade V (2 of 5) patients; of these patients, 33% of grade III and 30% of grade IV required subsequent splenectomy. CONCLUSION: Routine follow-up CT imaging after high-grade splenic injury identifies splenic artery pseudoaneurysm in a significant proportion of patients. Standardized surveillance imaging for high-grade splenic trauma promotes prospective identification of pseudoaneurysms, allowing for interventions to minimize delayed splenic injury complications. LEVEL OF EVIDENCE: Therapeutic/Care Management; level IV.

Immune function and the role of vaccination after splenic artery embolization for blunt splenic injury.

The spleen is the most commonly injured solid organ following blunt abdominal trauma. Over recent decades, splenic artery embolization (SAE) has become the mainstay treatment for haemodynamically stable patients with high-grade blunt splenic trauma, with splenectomy the mainstay of treatment for unstable patients. Splenic function is complex but the spleen has an important role in immune function, particularly in protection against encapsulated bacteria. Established evidence suggests that following splenectomy immune function is impaired resulting in increased susceptibility to overwhelming post-splenectomy infection, however, immune function may be preserved following SAE. This review will discuss the current state of the literature on immune function following different treatments of blunt splenic injury, and the controversies surrounding what constitutes a quantitative test of splenic immune function.

Damage control surgery for splenic trauma: "preserve an organ - preserve a life".

The spleen is one of the most commonly injured solid organs of the abdominal cavity and an early diagnosis can reduce the associated mortality. Over the past couple of decades, management of splenic injuries has evolved to a prefered non-operative approach even in severely injured cases. However, the optimal surgical management of splenic trauma in severely injured patients remains controversial. This article aims to present an algorithm for the management of splenic trauma in severely injured patients, that includes basic principles of damage control surgery and is based on the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia. The choice between a conservative or a surgical approach depends on the hemodynamic status of the patient. In hemodynamically stable patients, a computed tomography angiogram should be performed to determine if non-operative management is feasible and if angioembolization is required. While hemodynamically unstable patients should be transferred immediately to the operating room for damage control surgery, which includes splenic packing and placement of a negative pressure dressing, followed by angiography with embolization of any ongoing arterial bleeding. It is our recommendation that both damage control principles and emerging endovascular technologies should be applied to achieve splenic salvage when possible. However, if surgical bleeding persists a splenectomy may be required as a definitive lifesaving maneuver.

El bazo es uno de los órganos sólidos comprometidos con mayor frecuencia en el trauma abdominal y el diagnóstico oportuno disminuye la mortalidad. El manejo del trauma esplénico ha cambiado considerablemente en las últimas décadas y hoy en día se prefiere un abordaje conservador incluso en casos de lesión severa. Sin embargo, la estrategia óptima para el manejo del trauma esplénico en el paciente severamente traumatizado aún es controvertida. El objetivo de este artículo es proponer una estrategia de manejo para el trauma esplénico en pacientes politraumatizados que incluye los principios de la cirugía de control de daños en base a la experiencia obtenida por el grupo de Cirugía de Trauma y Emergencias (CTE) de Cali, Colombia. La decisión entre un abordaje conservador o quirúrgico depende del estado hemodinámico del paciente. En pacientes hemodinámicamente estables, se debe realizar una tomografía axial computarizada con contraste endovenoso para determinar si es posible un manejo conservador y si requiere angio-embolización. Mientras que los pacientes hemodinámicamente inestables deben ser trasladados inmediatamente al quirófano para empaquetamiento esplénico y colocación de un sistema de presión negativa, seguido de angiografía con embolización de cualquier sangrado arterial persistente. Es nuestra recomendación aplicar conjuntamente los principios del control de daños y las tecnologías endovasculares emergentes para lograr la conservación del bazo, cuando sea posible. Sin embargo, si el sangrado persiste puede requerirse una esplenectomía como medida definitiva para salvaguardar la vida del paciente.

Alterations of coagulation and fibrinolysis in patients with blunt splenic injury after splenic artery embolization.

BACKGROUND: Thrombotic complications following splenectomy have been documented. However, there has been sparse literature regarding thrombotic complications following splenic artery embolization (SAE).The objective of this study was to determine changes in coagulation and fibrinolysis and assess the thrombotic risk after SAE in patients with blunt splenic injury (BSI). METHODS: This study included 38 BSI patients who were hemodynamically stable on admission. SAE was performed if the splenic injury was classed as grade III or greater and had no requirement of immediate surgery. Platelet (PLT), fibrinogen (FIB), D-dimers (D-D), fibrinogen/fibrin degradation products (FDP), antithrombin III (AT III), prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), hemoglobin (Hb), and hematocrit (Hct) were measured before SAE procedures and then 1d, 3d, and 7d after SAE. RESULTS: The technical success rate of SAE and the splenic salvage rate were 100%. There was no mortality. Compared with pre-SAE values, the levels of PLT, FIB, D-D, and FDP increased significantly at 3 days and 7 days after SAE (p < 0.05). However, AT III, PT, APTT, TT, Hb, and Hct showed no statistically significant difference at 1d, 3d, and 7d after SAE (p > 0.05). CONCLUSION: Alterations in PLT and hemostatic parameters might contribute to the increased risk of thrombotic complications in BSI patients undergoing SAE. Thromboembolism following SAE should be considered and thrombotic prophylaxis should be recommended.

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 cost to perform splenic artery embolisation following blunt trauma: Analysis from a level 1 Australian trauma centre.

INTRODUCTION: Splenic artery embolisation (SAE) has been shown to be an effective treatment for haemodynamically stable patients with high-grade blunt splenic injury. However, there are no local estimates of how much treatment costs. The purpose of this study was to evaluate the cost of providing SAE to patients in the setting of blunt abdominal trauma at an Australian level 1 trauma centre. METHODS: This was a single-centre retrospective review of 10 patients who underwent splenic embolisation from December 2017 to December 2018 for the treatment of isolated blunt splenic injury, including cost of procedure and the entire admission. Costs included angiography costs including equipment, machine, staff, and post-procedural costs including pharmacy, general ward costs, orderlies, ward nursing, allied health, and further imaging. RESULTS: During the study period, patients remained an inpatient for a mean of 4.8 days and the rate of splenic salvage was 100%. The mean total cost of splenic embolisation at our centre was AUD$10,523 and median cost AUD$9959.6 (range of $4826-$16,836). The use of a plug as embolic material was associated with increased cost than for coils. Overall cost of patients requiring ICU was mean AUD$11,894 and median AUD$11,435.8. Overall cost for those not requiring ICU was mean AUD$7325 and median AUD$8309.8. CONCLUSION: Splenic embolisation is a low-cost procedure for management of blunt splenic injury. The cost to provide SAE at our centre was much lower than previously modelled data from overseas studies. From a cost perspective, the use of ICU for monitoring after the procedure significantly increased cost and necessity may be considered on a case-by-case basis. Further research is advised to directly compare the cost of SAE and splenectomy in an Australian setting.

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.

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.

A Rare Case of Walled-off Pancreatic Necrosis Complicated by Splenic Artery Rupture Manifested After Surgical Internal Drainage - Diagnostic and Therapeutic Aspects.

Large walled-off pancreatic necrosis (WON) is a well-known complication of severe acute pancreatitis, and it is associated with significant morbidity and mortality. This is the case report of a rare and potentially fatal complication of WON - a delayed splenic artery rupture close to its origin after surgical drainage. A 44-year old male patient admitted in our Surgical Department and diagnosed with WON evolving without infection for 6 months, after an episode of acute pancreatitis, underwent a Rouxen- Y WON-jejunostomy. In the 4th postoperative day patient presented melenic stools and a selective celiac trunk angiography was performed with the suspicion of a bleeding from the WON. At the initial injection of contrast a small leakage of contrast was observed but did not reappear despite repeated injection. The procedure was aborted, and the patient put under close observation. The 6th postoperative day bleeding re-occurred, and the angiography indicated a breach in the splenic artery. As the patient developed hemodynamic instability in the Radiology Department he was immediately transferred into the operating room and an exploratory laparotomy with suture of the splenic artery was performed. The patient had an uneventful recovery and at one-year follow-up was without any particular problems.

A Case of Successful Simultaneous Pancreas-Kidney Transplantation Using the Injured Pancreas Graft.

OBJECTIVE: Graft injuries sometimes occur and may cause complications such as the leakage of pancreatic secretions, which is often lethal. We report our experience of a case of successful simultaneous pancreas-kidney transplantation using injured pancreas graft. PATIENTS AND METHODS: The recipient was a 57-year-old woman with type 1 diabetes mellitus, and the donor was a 30-year-old man with a brain injury. In the donation, the pancreas parenchyma, splenic artery, and gastroduodenal artery were injured iatrogenically. We therefore reconstructed these arteries using vessel grafts and then performed simultaneous pancreas-kidney transplantation. RESULTS: Five days after transplantation, we noted a high titer of amylase in the ascites; therefore, we performed an urgent laparotomy. The origin of the amylase was the injured pancreatic parenchyma, and continued washing and drainage were carried out. We reconstructed the duodenojejunostomy using the Roux-en-Y technique to separate the passage of food from the pancreas graft to prevent injury to other organs due to exposure to pancreatic secretions. Thereafter, we inserted a decompression tube into the anastomosis thorough the blind end of the jejunum. Finally, we inserted 3 drainage tubes for lavage. Following this procedure, the patient recovered gradually and no longer required hemodialysis and insulin therapy. She was discharged from our hospital 56 days after transplantation. CONCLUSION: The restoration of the injured graft was possible by management of pancreatic secretions and use of the donor's vessel grafts. Shortage of donors is a problem throughout the world; thus, it is important to use injured grafts for transplantation if possible.

Overview of Nonoperative Blunt Splenic Injury Management with Associated Splenic Artery Pseudoaneurysm.

The delayed development of splenic artery pseudoaneurysm (SAP) can complicate the nonoperative management of splenic injuries. We sought to determine the utility of repeat imaging in diagnosing SAP in patients managed nonoperatively without angioembolization. We hypothesized that a significant rate of SAPs would be found in this population on repeat imaging. Patients undergoing nonoperative splenic injury management from January 2011 to June 2015 were queried from the trauma registry. Rates of repeat imaging, angioembolization, readmission, and SAP development were analyzed. Further, subanalyses investigating the incidence of SAP in patients managed nonoperatively without angioembolization were conducted. A total of 133 patients met inclusion criteria. Repeat imaging rate was 40 per cent, angioembolization rate was 26 per cent, and readmission rate was 6 per cent. Within the study population, nine SAPs were found (8/9 in patients with splenic injury grade ≥III). Of these nine SAPs, three (33%) were identified on initial scans and embolized, whereas six (67%) were found on repeat imaging in patients not initially receiving angioembolization. Splenic injuries are typically managed nonoperatively without serious complications. Our results suggest patients with splenic injuries grade ≥III managed nonoperatively without angioembolization should have repeat imaging within 48 hours to rule out the possibility of SAP.

Natural history of splenic vascular abnormalities after blunt injury: A Western Trauma Association multicenter trial.

BACKGROUND: Following blunt splenic injury, there is conflicting evidence regarding the natural history and appropriate management of patients with vascular injuries of the spleen such as pseudoaneurysms or blushes. The purpose of this study was to describe the current management and outcomes of patients with pseudoaneurysm or blush. METHODS: Data were collected on adult (aged ≥18 years) patients with blunt splenic injury and a splenic vascular injury from 17 trauma centers. Demographic, physiologic, radiographic, and injury characteristics were gathered. Management and outcomes were collected. Univariate and multivariable analyses were used to determine factors associated with splenectomy. RESULTS: Two hundred patients with a vascular abnormality on computed tomography scan were enrolled. Of those, 14.5% were managed with early splenectomy. Of the remaining patients, 59% underwent angiography and embolization (ANGIO), and 26.5% were observed. Of those who underwent ANGIO, 5.9% had a repeat ANGIO, and 6.8% had splenectomy. Of those observed, 9.4% had a delayed ANGIO, and 7.6% underwent splenectomy. There were no statistically significant differences between those observed and those who underwent ANGIO. There were 111 computed tomography scans with splenic vascular injuries available for review by an expert trauma radiologist. The concordance between the original classification of the type of vascular abnormality and the expert radiologist's interpretation was 56.3%. Based on expert review, the presence of an actively bleeding vascular injury was associated with a 40.9% risk of splenectomy. This was significantly higher than those with a nonbleeding vascular injury. CONCLUSIONS: In this series, the vast majority of patients are managed with ANGIO and usually embolization, whereas splenectomy remains a rare event. However, patients with a bleeding vascular injury of the spleen are at high risk of nonoperative failure, no matter the strategy used for management. This group may warrant closer observation or an alternative management strategy. LEVEL OF EVIDENCE: Prognostic study, level III.

Splenic artery embolization versus splenectomy: Analysis for early in-hospital infectious complications and outcomes.

BACKGROUND: Splenic artery embolization (SAE) has gained increasing acceptance as an important adjunct in the treatment of splenic injuries. Residual immunologic function of the spleen after embolization and its consequences on early infectious complications still remain intensely debated. The purpose of this study was to compare SAE and splenectomy (SP) in terms of early in-hospital infectious complications and outcomes. METHODS: Two-year retrospective Trauma Quality Improvement Program database prognostic study. Patients with grade IV to V splenic injury requiring SAE or SP were included in the final analysis. Examined variables were demographics, mechanism of injury, Abbreviated Injury Scale (AIS), Injury Severity Score, Organ Injury Scale, admission vital signs, blood transfusion in the first 24 hours, early infectious complications, and outcomes. Multivariate analysis adjusted for patient and injury-related variables was used to identify independent predictors for infectious complication and mortality. RESULTS: During the study period, 4,063 patients with a grade IV to V splenic injury managed with SAE or SP were included in the study. SAE was performed in 461 (11.3%) patients. The early infectious complication rate was 23.1% in the SP group and 11.7% in the SAE group (p < 0.001). Stepwise logistic regression analysis identified age 65 years or older, Glasgow Coma Scale (GCS) score less than 9, Head AIS score of 3 or greater, SP, and blood transfusion in the first 24 hours as independent predictors for early infectious complications. The unadjusted overall mortality was 12.7% in the SP group and 5.4% in the SAE group (p < 0.001). Age 65 years or older, GCS score less than 9, hypotension, head AIS score of 3 or greater, and blood transfusion in the first 24 hours were independent risk factor for mortality. SP was not an independent risk factor in terms of mortality. Subgroup analysis in patients with isolated splenic injury showed age 65 years or older, GCS score less than 9, and blood transfusion in the first 24 hours as independent factors associated with early infection. CONCLUSION: Our study supports the effectiveness of SAE in hemodynamically stable patients with a grade IV to V splenic injury. SP is associated with an increased risk of early infectious complications but is not an independent risk for mortality. LEVEL OF EVIDENCE: Therapeutic study, level IV.