1. 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

2. 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.

3. 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

4. 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

5. 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

6. 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

7. Clinical Questions
Does splenic artery angiography and embolization improve non-operative management outcomes?
Which patients should undergo angiography and embolization?

8. 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

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

10. 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 , when arterial embolization was no performed at the hospital
Gaardner, C, et al; J Trauma Jul;61(1):192-8

11. Study Outcomes

12. Complications

13. 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 Jul;75(1):69-74

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

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

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

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

18. Study Group Comparison
Miller, et al; J Am Coll Surg Apr;218(4):644-8

19. Study Results 2010-2012: Non-operative failure rate of 5%
Failure rate of 25% in 16 protocol deviations (p=0.02)
: Non-operative failure rate of 15% (p=0.04)

20. 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

21. 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

22. Future Directions
No prospective, head-to-head randomized clinical trial of SAE in non-operative splenic injuries
Limited data with respect to cost effectiveness

23. Splenic Injury Grading
Grade I:
Hematoma: Subcapsular, < 10% of surface area
Laceration: Capsular tear < 1 cm depth
Grade II
Hematoma: Subcapsular, % of surface area
Laceration: Capsular tear cm depth not involving trebecular vessel

24. 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

25. Splenic Injury Grading
Grade IV
Laceration: segmental or hilar vessels with > 25% devascularization
Grade V
Hematoma: shattered spleen
Laceration: total devascularization