Splenic trauma: Know the limits of embolization

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Hicham T Abada
Hicham T Abada

Management of blunt splenic trauma has substantially evolved during the past two decades. While some areas of controversy remain regarding patient selection for appropriate treatment, there are two clinical situations that have gained a large consensus among trauma surgeons. Hicham T Abada reviews the literature and outlines the limits of splenic embolization. He presented on the topic at the Global Embolization Symposium and Technologies meeting (GEST EU, 24–27 June in Seville, Spain).

 

First, patients with high-grade splenic injuries (stages IV–V) who are haemodynamically unstable are now directed systematically to the operative room as recommended by the American Association for the Surgery of Trauma (AAST). On the other hand non-operative management is to address those patients who are stable and with low-grade injuries (stages I–III). 

Now that non-operative management is well accepted in haemodynamically stable patients, one has to mention that splenic artery embolization plays a major role in this clinical setting by allowing a higher number of patients to be integrated into the non-operative management group. Further, embolization dramatically increases the success rate of patients in this group.

Initial clinical assessment is crucial in any trauma patient and data in surgical literature show that a mortality of 37% can be reached if inappropriate selection is made on admission. Although AAST has developed classifications and injury scoring system along with advanced trauma life support guidelines to help efficient triage of patients with blunt splenic injury, management of stable patients with various degrees of splenic injuries remain debatable. Imaging with mutidetector CT in an early report by Marmery et al. from 2006 shows that an accurate grading system can be obtained to predict which patient is suitable for non-operative management or for immediate surgical management. The CT-grading system described by Marmery has the added value of incorporating splenic vascular injury as pseudoaneurysms and fistula, in addition to depicting active bleeds that are not thoroughly present in the AAST classification.

Recent papers from Bhullar et al have demonstrated (in a cohort of 1096 patients) that embolization of patients with positive CT findings dramatically decreases the failure rate of patients in the non-operative management group. More interestingly, they were able to define a subgroup of haemodynamically stable patients with high-grade splenic injuries who showed significantly better outcomes if embolization was performed, compared to those who were not embolized in the same category.

Similarly Miller et al have prospectively studied patients with high-grade splenic injuries (stages III–IV). They have found that, even with integrating stage III patients who were stable, embolization significantly improved the success rate of non-operative management. Both authors suggested in the light of their empiric experience and recent retrospective and prospective data that embolization of high-grade splenic injuries, irrespective of the presence of the active extravasation of contrast media, significantly improves outcomes.

Saksobhavuvat et al also recently compared various clinical parameters and used a CT-based grading system to triage splenic trauma patients. From their data, it appears that CT represents the best tool for treatment planning and for choosing non-operative management and splenic intervention in haemodynamically stable patients. It is very important to highlight that this study clearly showed that not a single patient received unsuccessful non-surgical management when CT is used for triage.

Finally, if we have to address the limits of embolization in blunt splenic trauma, we can readily mention that we should not embolize haemodynamically unstable patients with high-grade injuries (IV–V) as it is specifically not recommended by any trauma or surgical society guidelines. On the other hand, all stable patients with active bleed, non-bleeding vascular injury such as pseudo aneurysm and fistula have shown a clear clinical benefit, when treated with embolization.

More recent data have also shown that the efficacy of embolization in patients in whom high-grade splenic injuries are identified, but who are in but in stable haemodynamic status. Embolization in this latter group is suggested irrespective of the demonstration of active extravasation or not.

Hicham T Abada is chief of Interventional Radiology, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE. He has reported no disclosures pertaining to this article.