Jamaica Hospital Trauma Conference July 21st, 2014 Greg Eckenrode Role of Arterial Embolization in Non-Operative Management of Splenic Injuries Jamaica Hospital Trauma Conference July 21st, 2014 Greg Eckenrode ADVANCING SCIENCE, ENHANCING LIFE

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