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Emergent Transcatheter Arterial Embolization in Hemodynamically Unstable Patients With Blunt Splenic Injury

Posted Jan 31, 2008 Updated Apr 7, 2023
By Wei-Ching Lin MD , Yung-Fang Chen MD , Chien-Heng Lin MD , Yuan-Hong Tzeng MD , Hsein-Jar Chiang MD , Yung-Jen Ho MD , Wu-Chung Shen MD , Jeon-Hor Chen MD
6 min read

Rationale and Objectives

Splenic preservation is currently the trend for treatment of patients with splenic trauma to avoid complications of splenectomy. This study aimed to evaluate the feasibility of emergent transcatheter arterial embolization (TAE) for hemodynamically unstable patients with blunt splenic injury.

Materials and Methods

In a period of 2 years, 65 patients of blunt splenic trauma were studied. Patients with initial systolic blood pressure < 90 mmHg and showed initial response including rapid response and transient response to the emergent fluid resuscitation were included. Angiography and TAE was undertaken if contrast medium extravasation or pseudoaneurysm formation was noted in the computed tomography (CT) images, according to the criteria of American Association for the Surgery of Trauma. All patients who underwent TAE were admitted for observation of the possibility of delayed rupture.

Results

Thirteen hemodynamically unstable patients who were responsive to initial fluid resuscitation received angiography due to abnormal CT findings including contrast agent extravasation in 12 patients, 2 patients with arteriovenous fistula, and 8 patients with pseudoaneurysm formation. TAE was successfully performed in all of these 13 patients, including 2 patients with associated left renal injuries and 1 patient associated with bilateral internal mammary arteries injuries, without complications.

Conclusions

TAE is a safe and effective procedure for treating blunt splenic injury even in hemodynamically unstable patients who responded to initial fluid resuscitation.

Management of blunt splenic injuries has been changed from splenectomy toward splenic preservation such as use of hemostatic agents, suture of the laceration, partial splenectomy, and splenic reimplantation. Even so, these techniques may induce rebleeding or exacerbate bleeding from splenic injuries when the spleen was mobilized from its bed for remove all the blood clots from its surface.

Conservative treatment with bed rest and observation was used in pediatric patients of splenic injury with stable hemodynamic stable condition. When this was extended to the hemodynamic stable adult patients, it showed a relative high failure rate and hence is less encouraged ( ). Keramidas first reported successful splenic hemostasis by surgical ligation of the proximal splenic artery in 1979 ( ), and Sclafani et al had translated this concept into a percutaneous approach ( ). It was supposed that embolization of the proximal segment of main splenic artery would reduce the pressure in the spleen, help to heal the injury, and decrease the risk of secondary rupture of the spleen. After that, several similar studies with percutaneous transcatheter arterial embolization (TAE) were reported in effective control of bleeding for hemodynamically stable patients with blunt splenic injury and preserve the splenic function ( ), in contrast to the high failure rate of traditional nonoperative treatment of splenic injuries with strict bed rest and observation. The method of TAE in hemodynamic stable patients has shifted from embolization of the main trunk of the splenic artery to superselective embolization close to the bleeder. Although several reports proposed that embolization of the main trunk could preserve the splenic function by reperfusion via the collateral circulations but superselective embolization can reduce the infarction region to as small as possible.

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Materials and methods

Patients

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Figure 1, Algorithm for splenic injury management following advanced trauma life support (ATLS) guideline.

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CT Imaging

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Table I

CT grading of splenic injuries according to the American Association for the Surgery of Trauma

Injury Grade Description of Injury Splenic hematoma I Subcapsular <10% surface area II Subcapsular 10–50% surface area; Parenchymal <5 cm in diameter III Subcapsular >50% surface area Ruptured subcapsular or parenchymal hematoma; Parenchymal >5 cm in diameter IV Parenchymal ruptured Splenic laceration I Capsular tear, <1 cm parenchymal depth II Capsular tear, 1–3 cm parenchymal depth that doesn’t involve a trabecular vessel III Parenchymal depth, >3 cm or involving trabecular vessels IV Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen) V Completely shattered spleen V/Vascular Hilar vascular injury that devascularizes spleen

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Angiography and TAE

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Post-TAE Care and Follow-up

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Statistics

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Results

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Figure 2, A 19-year-old young male with grade IV splenic injury from a motorcycle accident. Contrast enhanced computed tomography (CT) in axial section (a) and reformat coronal image (b) showed contrast medium extravasation (black arrows) via the upper pole of the spleen. Poor perfusion in the upper part of the spleen (open arrow) and large amount of hemorrhage surrounding the spleen (stars) was noted. Angiography of celiac artery (c) revealed no prominent contrast medium extravasation but multiple small abnormal blush within the parenchyma of the spleen (black dot line circle) were noted. After superselective embolization of the superior branch of the splenic artery by stainless steel microcoils (arrow head) via 3 Fr microcatheter, immediate celiac angiography (d) showed no evidence of contrast medium extravasation or other abnormal vascular stain. (e) Follow-up CT 14 days later demonstrated a focal infarction area (black dot line circle) and microcoils induced metallic artifacts (arrow head).

Figure 3, A 79-year-old male with grade III splenic injury from falling from 2 m. Contrast-enhanced computed tomography in arterial phase in axial section (a) , maximum intensity projection (MIP) (b) , and volume rendering (VR) reformation (c) images revealed a pseudoaneurysm (white arrow) within the parenchyma and early venous return indicating arteriovenous fistula formation (blue arrow). Selective splenic arteriogram (d) demonstrated arteriovenous fistula (white arrow) with early opacification of the splenic vein (blue arrow). Immediate follow-up splenic arteriogram (e) after superselective embolization of the inferior branch of the splenic artery with microcoils (white dot line circle) showed another contrast medium extravasation in the mid-portion of spleen (black arrow head with dot line tail). Splenic arteriogram (f) after embolization of a small artery (black arrow head with dot line tail) arising from the superior branch of the main splenic artery showed no contrast medium extravasation or other abnormal stain.

Figure 4, A 65-year-old female patient with grade III splenic injury due to traffic accident. Continuous two sections of contrast enhanced computed tomography (a,b) in arterial phase in the splenic hilar level revealed abnormal blush (black dot line circle) in the posterior portion of the splenic hilum. Anteroposterior splenic arteriogram (c) showed some contrast medium extravasation (black dot line circle) in the inferior portion of spleen near the hilum. After catheterization of the main trunk of the splenic artery near hilum with a 3 Fr microcatheter, Gelfoam cubes were infused for vascular embolization. Follow-up splenic arteriogram (d) after transcatheter arterial embolization demonstrated no contrast medium extravasation or abnormal blush within the spleen.

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Discussion

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Conclusion

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References

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Academic Radiology, Volume 15, Issue 2
Journals General Radiology
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